Provider Demographics
NPI:1275015133
Name:JOHNSON EYECARE, LLC
Entity Type:Organization
Organization Name:JOHNSON EYECARE, LLC
Other - Org Name:JOHNSON EYECARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:339-221-4549
Mailing Address - Street 1:8584 BIG MANGROVE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-7694
Mailing Address - Country:US
Mailing Address - Phone:339-221-4549
Mailing Address - Fax:
Practice Address - Street 1:15661 SAN CARLOS BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-2797
Practice Address - Country:US
Practice Address - Phone:339-221-4549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZOPC4329261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL720219Medicaid